DCMS #150:

For the past eight years, both Steve Freed and I have been delivering CEU’s on medical errors to pharmacists and nurses, and we are frequently asked what the biggest causes of errors are. After giving this considerable thought, I believe that repetitive tasks are a major cause of medication errors. Many health professionals repeat the same process over and over, and are on "remote control" during these tasks, doing them without even thinking. This problem is exacerbated by long shifts and short staffing. Our Disaster Averted this week looks at the dangers associated with insulin infusion in the hospital and what happens when there is not enough care and emphasis put on IV bags containing insulin, and no one believes a mistake can be made.